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Depression in older patients: Recognition and treatment

The history and examination are key to ruling out nonpsychiatric causes in older adults, whose depression is often expressed in somatic complaints.

M. Rebecca Buckley, MHS, PA-C; Vicki D. Lachman, PhD, APRN, MBE

Rebecca Buckley works clinically in psychiatry and is on the faculty at the Drexel/Hahnemann PA program, Philadelphia, Pennsylvania. Vicki Lachman is on the graduate nursing faculty at Drexel University. The authors have indicated no relationships to disclose relating to the content of this article.

Geriatric patients commonly present to primary care practices with depressive disorders, but unfortunately these disorders often go unrecognized. This article reviews the diagnosis and treatment of depression in older patients, with the objective of helping PAs to recognize the condition and treat it appropriately.

PREVALENCE AND RISK

Depression goes unrecognized or underdiagnosed in approximately 16% of the older patients seen in primary care settings.¹ Even when it is recognized, clinicians may hesitate to prescribe medication because of lack of confidence or concern about adverse effects.^2,3 Classically, older adults deny being depressed, minimize the severity of symptoms, fail to recognize anhedonia or fatigue as symptoms of depression, and hesitate to admit illness.⁴ In the most recent published study, Steffens and colleagues estimated the prevalence of major depression to be 4.4% in elderly women and 2.7% in elderly men.⁵ In other studies, point prevalences ranged from 10% to 20% in the community or primary care settings and from 15% to 25% or higher in medically ill groups.^6,7

The likelihood of a depressive disorder increases approximately 1.5 to 3.5 times if a patient has a chronic illness, chronic pain, significant recent stress, or undiagnosed symptoms and signs.^8,9 For a more inclusive list of the risk factors for depression in the elderly, see Table 1.

IDENTIFYING DEPRESSION IN OLDER PATIENTS

According to the Depression Guideline Panel, a thorough medical history and physical examination are essential in ruling out physiologic and pharmacologic causes of depressive symptoms.¹⁰ This is especially important in older adults, whose depression is frequently expressed in multiple somatic complaints.

Clinicians should explore six crucial areas to differentiate geriatric depression from other medical conditions or medication-induced symptoms.

First, understand that your patient may have both depression and another disorder. Practitioners are less likely to ask older patients about depression, less likely when making the diagnosis to ask about suicidal ideation, and, ultimately, less likely to offer comprehensive treatment.¹¹

Second, remember that a few medical conditions may manifest with depressive symptoms¹² (see Table 2). Take care either to rule out or treat any medical conditions that may be causing such symptoms. Remember too that geriatric patients will have comorbidities. Depression affects at least 25% of people with chronic diseases and may affect close to 50% of patients in nursing homes.¹³ Depression is also frequently associated with diseases that produce chronic pain, such as rheumatoid arthritis, osteoarthritis, systemic lupus erythematosus, and neuropathies. Dementia and depression can be difficult to differentiate because of their similar effects on memory; clinicians should be aware of the differences between them^13,14 (see Table 3).

Third, a social history is vital for diagnosis because any significant personal loss may precipitate a depressive episode. Geriatric patients may have recently lost loved ones, friends, family members, or beloved pets—or they may have lost independence, both physical and intellectual. Sadness and depression are never a “normal” part of aging.

Only a minority of bereaved individuals continue to suffer from emotional problems.⁹ Horowitz and colleagues discuss the symptoms of complicated grief, which often leave the person in a prolonged state of mourning.⁹ In one study, a negative view of the emotions of grief emerged as the most important predictor of depression.¹⁵ Therefore, it is crucial for the PA to normalize grief reactions and refer the patient to support groups or, in more severe cases, to cognitive or interpersonal therapists for help.

The history should consider the use and abuse of prescription medications, illicit drugs, and alcohol, as well as any loss or change in sexual function. Drug and alcohol abuse not only causes depression but can also affect management: even moderate drinking in late life is associated with a poor response to standard depression treatment.¹⁶ Diminished sexual function may be due to a medical condition, but it may also be a sign of anhedonia.

Because many prescription, OTC, and illicit drugs may cause or contribute to depressive symptoms, a clear medication history is essential¹⁷ (see Table 4). This history should include how long patients have been taking the drug, why they are taking it, who prescribed it, and when the last dose was taken. Ask patients to bring in all medications at least every 6 months, including OTC drugs, herbal and vitamin supplements, and topical agents. According to the National Institutes of Health, geriatric patients are taking an average of at least five medications—more if they are in a nursing home.

Fourth, understand that elderly patients frequently do not present with the classic criteria for major depressive disorder (MDD) as described in the DSM-IV-TR.¹⁸ For example, depression is the most common cause of weight loss in the elderly.¹⁷ Pain is one of the most common chief complaints in elderly patients suffering from depression.^13,17 The pain complaints associated with depression are typically exaggerated and involve multiple systems (GI, neurologic, musculoskeletal), and somatization may be involved. Also ask about other common symptoms of depression in the elderly, such as memory loss, agitation, insomnia, fatigue, and decreased appetite.

Fifth, studies reveal that of elderly patients who commit suicide, 20% saw a health care provider that day and 40% saw one within a week of their suicide.¹⁹ Older patients have multiple risk factors for suicide. As with all patient populations, when there is a positive response to “Do you have any thoughts of hurting yourself or ending your life?” the PA must follow-up with these questions: Do you have a plan for how to commit suicide? Do you have access to weapons or means to commit suicide? Have you ever tried to commit suicide in the past? Do you have anyone to support you and be with you now? Is there any family history of suicide? The clinician should document responses to the questions and construct a plan of action.

Sixth, perform a complete physical examination, including a rectal examination to look for occult blood and a thorough mental status examination to assess cognitive function and mood. The laboratory workup should include a thyroid- stimulating hormone level, CBC with differential, chemistry panel including electrolytes and fasting blood glucose, B₁₂ and folate levels, and—when indicated—a chest film, ECG, and medication levels.²⁰

A number of tools can be used to screen for depression, but which is the best? The Center for Epidemiologic Studies Depression Scale (CES-D) is the most widely studied depression scale and is commonly used for community dwelling and medically ill older adults.^20,21 A 10-item version of the CES-D was developed and validated, and takes about 2 minutes to administer (see Center for Epidemiologic Studies Short Depression Scale).

An even briefer tool designed for emergency department use was tested on 267 patients, aged 70 to 102 years.²² This tool asks two questions: “During the past month, have you been bothered by feeling sad, down, depressed or blue?” and “During the past month, have you had little interest or pleasure in doing things?” With a positive answer to one question, the tool’s sensitivity to detecting depression is 84%.²² A patient who answers Yes to one question should then be screened with the 10-item CES-D.

PHARMACOLOGIC AND NONPHARMCOLOGIC TREATMENTS

As of 2007, the evidence base for treatment of minor depression in the elderly is limited.²³ The few randomized controlled trials focusing on the elderly patient suggested that antidepressant medication or depression-specific counseling methods have a relatively modest benefit.^23,24 However, interpersonal psychotherapy and cognitive behavior therapy have well- documented efficacy in randomized controlled trials, compared to medications, for elderly patients with mild to moderate depression.²⁵ The combination of pharmacotherapy and psychotherapy has been shown to be the most efficacious treatment for severe depression, though results are mixed.¹¹

When writing a new prescription for a geriatric patient, practitioners must consider cost, side effects, ease of dosing, drug interactions, and pharmacokinetics. Before starting any new medication, the PA must have baseline knowledge of the patient’s hepatic and renal function. Also important to remember with psychiatric medications, older patients are more sensitive to anticholinergic effects (blurred vision, dry mouth, urinary retention, and constipation), which are most commonly seen with tricyclic antidepressants (TCAs) and paroxetine; the sedative effects of benzodiazepines and analgesics, which contribute to falls; and to any cardiovascular effects that may produce decreased cardiac output or hypotension.²⁶

An inadequate length of treatment or inadequate dosing can lead to treatment failure. The standard of practice is to treat a patient for 8 to 12 weeks before switching medications or adding a second drug. Start low and go slow, as the saying goes. Try starting the antidepressant at half the normal dosage; titrate it up slowly while closely monitoring response and, if needed, renal and hepatic function. Once stabilized and feeling better, the patient should continue taking the antidepressant for 1 year after the first episode of depression, 2 years after the second episode, and 3 years or indefinitely after the third epsiode.¹² Some people will chronically relapse, and with elderly persons at increased risk because of comorbid medical conditions, treating them for life may be a wise decision. The minimally effective dosage should be continued during maintenance therapy. The goal of treatment of depression is the resolution of all symptoms, not just an improvement of mood.

Selective serotonin reuptake inhibitors (SSRIs) are considered the first-line pharmacologic treatment—unless a patient has bipolar disorder, in which case SSRIs may induce a manic episode. In patients with unipolar depressions, these agents have fewer side effects compared with selective norepinephrine reuptake inhibitors, atypical antidepressants (mirtazapine), TCAs, and monoamine oxidase inhibitors (MAOIs). Most common reactions include transient GI distress, sleep disturbance, excessive sweating, fatigue, headache, and sexual dysfunction. More serious reactions such as extrapyramidal symptoms and hyponatremia may occur. SSRIs are dosed once a day to improve adherence. Escitalopram and sertraline are recommended for the geriatric population because of their long half-life, which is approximately 24 hours.¹³

Clinicians should be alert to the withdrawal syndrome that can occur with SSRIs and to their potential for toxicity. Withdrawal symptoms may occur when SSRIs have been taken for longer than a month. Withdrawal syndrome occurs within 48 hours of abrupt discontinuation with the short- acting drugs and can last from 10 to 14 days. Symptoms include dizziness, incoordination, disorientation, parathesias, sleep disturbances, GI upset, and agitation. The risk can be reduced if the dosage is tapered over a 2- to 3-week period.¹⁷

Serotonin syndrome occurs when a patient takes too much of the SSRI or combines it with other medications that inhibit the cytochrome (CY) P450 hepatic system. Symptoms include hyperthermia, muscle rigidity, myoclonus, and changes in mental status and vital signs. An SSRI should always be discontinued 14 days before starting an MAOI because the incidence of serotonin syndrome increases when drugs of these classes are combined. Sertraline, citalopram, and escitalopram are weak CY-P450 inhibitors and therefore less likely to interfere with other drugs.

Venlafaxine and bupropion may also be considered based on the patient’s symptoms. Their effects on norepinephrine and dopamine make them a potentially good choice for a patient whose predominant or resistant symptoms are fatigue, apathy, and/or difficulty concentrating. They are better dosed in the morning because they have energizing effects. The atypical antidepressants such as trazadone and mirtazapine are sedating and may be added at bedtime in small doses if insomnia is persistent. Mirtazapine’s antihistamine effects make it a good choice for patients with anorexia.

TCAs should be used with caution in the geriatric population because of their substantial anticholinergic effects. Desipramine and nortriptyline have the least side effects of this class. According to the National Center for Health Statistics, amitriptyline tops the list as the most inappropriately prescribed psychiatric medication in the elderly. Benzodiazepines are second. Amitriptyline has significant anticholinergic effects, is highly sedating, and causes postural hypotension.

Suicide attempts increase after initial treatment with an antidepressant drug. Some experts believe this occurs because fatigue improves with treatment before mood does; thus, people who lacked the energy to follow through on suicidal thoughts are no longer immobilized early in treatment. This is another reason for vigilant follow-up in the weeks after initiating pharmacologic treatment.

St. John’s wort (Hypericum perforatum) is one of the most frequently used herbal medicines for the treatment of depression. Some recent placebo-controlled trials imply that Hypericum has minimal helpful effects on MDD, while other trials suggest that Hypericum and standard antidepressants have similar favorable effects.²⁷ St. John’s wort interacts with a range of medications, and it is best limited to use in patients with mild to moderate depression.^27,28

Light therapy, or phototherapy is now the treatment of choice for seasonal affective disorder. It has a fast onset, causes few side effects, and can be administered with medication and/or psychotherapy.¹¹ The usual treatment is at least 30 minutes of bright light (10,000 lux), in the morning throughout the fall and winter, using a standard phototherapy device.²⁹ A 2006 review of 49 randomized controlled trials of light therapy found that it offers modest though positive antidepressant efficacy.³⁰ In 2003, the American Psychiatric Association task force on light therapy recommended that it be included in the therapeutic arsenal.³¹

Referral is important to the treatment of geriatric depression, and PAs should be prepared to refer when the diagnosis is uncertain, the symptoms are severe, the circumstances are urgent (including psychosis), the treatment regimen is complicated, or first-line agents have failed to resolve symptoms.

Severe MDD with psychotic features is best treated with electroconvulsive therapy (ECT) when antidepressant medications are not an option.³² In fact, in one study, ECT was significantly more effective in patients older than 65 years than in those younger than 45 years.³² A typical course of ECT is 6 to 12 treatments, with treatments given two or three times a week; improvements with this protocol are often noted in the fourth week.³²

CONCLUSION

Primary care PAs are in excellent position to recognize the early signs of depression in the elderly patient through a systematic assessment. Often community support to decrease isolation, improve nutritional status, and provide meaning in the patient’s life is sufficient treatment. But for moderate to severe depression, medication and psychotherapy is often necessary. With proper diagnosis and adequate treatment, 54% to 84% of geriatric patients suffering from depression recover and return to their normal level of functioning.¹²

DRUGS MENTIONED

REFERENCES

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